A New York Times article Saturday, “Cut Back on Tamiflu, U.S. Official Says”, by Donald G. McNeil, Jr. reports that the Centers For Disease Control (CDC) is asking kids’ summer camps to stop distributing Tamiflu prophylactically, because the agency worries that “giving the drug to healthy people wastes the world’s limited supplies of Tamiflu and increases the chances of drug-resistant strains developing.”
To me, this is particularly interesting, because it reveals a tension between what may be the best preparedness decision for the individual (and the specific community — ie. a camp), and what is likely the best preparedness decision for the nation (and society). It is a conflict that can occur in disaster preparedness and response and presents a challenging public education point for authorities to deal with.
As I mentioned in a post earlier this week, “H1N1 Hits Home, I’m On Tamiflu,” I (along with my oncologist) had to decide a course of action after someone in my family was diagnosed with H1N1. Because I am recovering from Leukemia and have just finished chemotherapy, she recommended that I take Tamiflu (which follows the CDC’s guidance for people with underlying illnesses). But giving the antiviral to healthy kids this summer raises a more difficult issue, particularly since the camps have found it to be a successful way of stopping the flu’s spread. In his article, which covers the press briefing given yesterday by Dr. Anne Schuchat, director of the National Center on Immunization and Respiratory Diseases, McNeil writes:
Giving the drug to healthy people wastes the world’s limited supplies of Tamiflu and increases the chances of drug-resistant strains developing, Dr. Schuchat said, and the disease centers are working with camp associations and local health departments to discourage the practice. Dozens of camps have had swine flu outbreaks this summer. Some closed, others set up infirmaries, and some have had camp doctors write Tamiflu prescriptions or asked parents to send children with the drug.
The practice is controversial because public health authorities consider it selfish and dangerous. Although there is a national stockpile of 50 million courses of Tamiflu, it will not last into the coming flu season if many healthy Americans start taking the drug.
The director of Camp Modin, one of the Maine sleep-away camps that offered prophylactic Tamiflu, disagreed with Dr. Schuchat’s recommendation. ”The evidence speaks for itself,” said the director, Howard Salzberg. “I have no children with swine flu at this moment, and we are confident that the Tamiflu helped us remedy the situation.”
The full transcript of the briefing by Dr. Schuchat (who I had the chance to interview on video at the H1N1 Preparedness Summit earlier this month) can be found here. In her answer yesterday, she further explained the agency’s position and actions on the summer camps and Tamiflu.
I don’t think that’s a good idea, the prophylactics to all campers. What I can say is we have guidance about anti-viral medicines and the best ways for them to be used. We’ve been working closely with the camp associations and with the health departments who work locally with their camps, and we really want the public to know that anti-viral medicines are important. They’re part of our armamentarium. I think another important thing to say is we have the resistance to Tamiflu in the new virus.
I believe now there are about five cases that have been reported that are Tamiflu resistant. That’s a very small number compared to the very large number of cases we’re seeing around the world. But we have seen with other influenza viruses them taking off with a low level of resistance to virtually all strains being resistant. We think it’s important to be careful about how the medicines are used but there are circumstances where preventive use of anti-virals is still important in people who have severe medical problems, who have been in very close contact with someone with influenza. So I think our efforts are really trying to make sure people know the right way to use the medicines, the role that they play and the risk of resistance that’s out there that we don’t want to get any worse.
An argument can be made, of course, that what might actually be in the short-term interest of the campers is not really in their long-term interest if somehow the widespread prophylactic distribution leads in some way to a worse outbreak in the Fall. But in the short-term it’s a tough case to make to the kids, their families and camp administrators who feel that the Tamiflu cut down on a lot of illness this summer.
I am not an expert (or even a novice) at the medical questions involved. But I think it’s important to highlight the ‘personal vs. societal interest’ issue not only for H1N1 but also because it is something that has and will come up in other major emergency situations. In fact, it might be helpful for officials to actually say explicitly that they may be making recommendations that might seem (or may actually be) contrary to an individual’s best interest in order to achieve broader national public health goals. And, the Tamiflu prophylactic decision is one of those instances.